The Lady with Worms Coming Out of Her Skin

The Lady with Worms Crawling Out of Her Skin – An Unusual Case

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People who know Dr. Darko well know that, after over 30 years of treating patients in major medical centers, he has a lot of stories he can tell (though always keeping patient confidentiality). One of his odd, really odd, cases from years ago is the case of the lady with worms crawling out of her skin. It’s a true story, and yes, the desperate woman did have to ricochet from city to city and specialist to specialist trying to find an answer, have a diagnosis from a doctor, and find a treatment that would cure her.

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The Case of the Lady with Worms Crawling Out of Her Skin

She was a blond from Las Vegas. One could envision her strolling the Las Vegas Strip in the evening, dressed to the nines and out on the town. She had finally, in desperation, brought herself to the big renowned medical center on the coast for help. After seeing several physicians in Las Vegas and not getting an answer much less a treatment, she saw a few more physicians in Reno. Having the feeling that she was being dismissed as some kind of nut, but really distressed about these worms that occasionally crawled out of her skin, she traveled to the large regional referral clinic where our CEO was a Division Head in the Department of Medicine. Given her complaint, the main front lobby referral desk didn’t quite know what to do with her, so as a starting point they scheduled her into the General Internal Medicine Clinic.

One of our Nevada Readers Asked:

Why would this woman feel she had to go to some supposedly fancy clinic in California? There are plenty of good doctors in Las Vegas.

That’s difficult for us to say without ruffling some feathers, and it might well be that in recent years the medical expertise in Las Vegas had grown. The answer probably also has to do with local California snobbery, that unless you go to the East Coast there’s nothing that compares with the great medical centers on the West Coast. That said, our lady did originally place her faith in her local Las Vegas medical community. Failing that, she next tried the Reno, Nevada, physician community. Only as a last resort did she head for the coast.

The Start of Any Medical Visit – The Chief Complaint

So, our story continues with our lady at the check-in desk for the General Internal Medicine Clinic. The referral form in her hand from the front lobby referral desk listed her Chief Complaint as, “Worms crawling out of my skin.” It was an unusual enough chief complaint that it startled the front desk administrative assistant. She asked the lady to have a seat and quickly scooted back to a group of doctors to ask if this patient was in the right place and, if so, with which doctor she should schedule her. The general opinion of the medical professionals was to slot the woman into the next open exam room, just like any other patient. About 15 minutes later an exam room, cleaned and readied, opened up for a next person. Our Las Vegas lady was escorted from the waiting room to the exam room.

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Enter the “More Than a Little Curious” Physicians

Exam rooms in medicine clinics are most always small, sparce, and maybe chilly. This one was typical. She sat there for about 15 minutes waiting. One of the internists knocked on the door and then popped into the exam room to see her. There was an entourage. With the good senior doctor in a full-length white coat was a resident doctor, an intern, and a medical student. “Oh, God,” she thought, “A whole medical team on a learning expedition.”

Getting to the Facts of the Medical Problem

At least they all seemed really interested as she described to the four of them, internist, resident, intern, and med student, that, every now and then, maybe once every week or two, a worm would crawl out of the skin and scare the hell out of her. It scared her to death to think that she had worms inside her. And, she knew they were in her because one would occasionally crawl out. No, she couldn’t show them any of the places where one had come out because a few days after one comes out the little hole had healed closed. And, no, unfortunately, she doesn’t have any of the dead worms to show them. When one comes out it upsets her and she quickly brushes it really hard to get rid of it but then when she looks for it she can’t find the worm anywhere.

The Dilemma of the Negative Medical Exam

The senior internist gathered her medical history in textbook fashion as he was teaching the other three how to do it properly. It all seemed pretty normal for a woman who grew up in rural Nevada and moved to Las Vegas for work after high school. She had been fairly healthy throughout her life, trying to live a healthy lifestyle as an attractive young blond in Las Vegas. Height, weight, and BMI (body mass index) were average, and visual acuity was normal. She smoked a lot and drank a little, didn’t exercise much, and ate a surprisingly healthy diet, given everything else.

So Nothing to Find on the Medical History and Physical Exam

Her blood pressure was normal and her vaccinations were up to date. The exam of her heart and lungs were normal, as was her abdominal exam. She had no history of sexually transmitted diseases and no history of psychiatric or neurological conditions. At the end of the visit, after the intern and medical student went on their way, the internist and resident did a breast exam, Pap smear and pelvic. Laboratory tests were ordered for lipids, glucose, blood chemistries, and urinalysis.

Where to Go Next – The Referral Chain

After two hours, with the early results in hand, the four of them, internist, resident, intern, and medical student, discussed where to send her next. It was unlikely that anything would come back from the pending labs to explain the chief complaint of “worms”. But this General internal Medicine gang had hit a brick wall with no ideas. Maybe Dermatology? No, the internists found nothing for the docs in Dermatology to see. Probably they should refer her next to Infectious Diseases. Yeah, right, there’s that doc in Infectious Diseases who knows a lot about tropical infections and infestations, like parasites, like worms that get into people. The team writes down her medical history, the resident records her physical exam, the intern fills out the needed paperwork, and they send it all off to the scheduling desk to make an appointment with Parasitology in Infectious Diseases.

Wriggling Into and Out Of Parasitology

That main guy, the parasitologist who knows this stuff, was on vacation, so they schedule her for the next week. She has to go home to Las Vegas and then travel back to the clinic. The internist does instruct her that, if a worm comes out before her appointment in parasitology she should try to collect it in a bottle and bring it to show the Infectious Disease staff. She returns the next week, no worm in a bottle, because no new ones had wiggled out. The parasitologist hears her story and does his physical exam. He did get one valuable piece of information that had not come out before. The worms only seem to come out of her forearms and hands. He examines her forearms and hands with a magnifying headlamp. The skin is roughened more than it should be for her age but no sign of worms.

There Really Are Worms That Crawl Out of the Skin

There really are worms that can crawl out of a person’s skin. One is the guinea worm that comes from drinking contaminated water. It goes from the consumed water out of the person’s stomach, moves about in their body for about a year, then comes out through the skin. But, a guinea worm didn’t fit with growing up and living in Nevada. There’s the chigoe flea (or jigger flea or sand flea), a parasite that grabs onto a person’s skin. But chigoe fleas are on the skin, not popping out of the skin. Filarial worms? No. Screwworm? No. Common louse? No, that doesn’t fit either. Nothing fit. There was no worm infestation that fit this woman’s history, physical exam, and description, even with a wide, wide stretch of the imagination. Now what? To which Medical Division to refer?

When Something Is Wrong and No One Knows Why – The Psychiatry Division

The internist and parasitologist talked about the case over lunch. A surgeon and a radiologist were sitting at the same table in the doctor’s lunch room and joined the discussion. This foursome snagged a pathologist on his way out, and he sat down, too. What to do, what to do? There is this syndrome called “delusional parasitosis”. Maybe she has that. Her story doesn’t make all that much sense. Maybe she’s just crazy. No one has actually seen one of the worms, or any holes where they came out. Dr. Darko is the Division Head of Psychiatry, send her to him. He’s good. Maybe he can solve this medical mystery. After all, she must have delusional something!

What in the World is Delusional Parasitosis?

Obviously delusional parasitosis is a “mental” disorder. That is, a physical brain disorder that everyone calls a “mental” disorder. (See our page on Your Mind & Your Brain.) A delusion is a fixed false belief. People who have this specific delusion falsely believe that they are infested with some living creature. Like, for example, a parasitic worm. Of course, like most “mental” disorders, no one knows what causes it. If there’s no other sign or symptom of psychosis and the belief’s gone on for at least a month, and there’s no other explanation, then it’s delusional parasitosis. If so, a medicine for psychosis will fix it right up. Oh, and while it is rare, it is seen twice as often in women as in men, so, there you have it.

The Looney Bin is Not A Bin and Not Filled with or Run by Loonies

You’d have to know Dr. Darko to know what to expect next. While he’s not strictly an internal medicine doc, he is a Fellow of the American College of Physicians, and has been for almost 40 years. Most of his 30 year clinical career was as a consulting psychiatrist to everywhere in a general medical/surgical hospital. He’s also done his time in the psychiatrist’s chair, of course, but on occasion has stood nose-to-nose with many an internist and surgeon telling them just which patient does have a problem and which one’s not crazy. And so it was in that very chair in the office of the Head of the Psychiatry Division in the Department of Medicine that the blond lady from Las Vegas later found herself.

You Mean There’s Really A Medical History Here?

Of course, the referral paperwork needed to travel around in the innards of the clinic first. The woman from Las Vegas had to again go home and get on the schedule to be seen in Psychiatry. And she was not happy about it. Not at all happy about it. She had damn worms crawling out of her skin and people thought she was crazy. This all took place back in the good old days of paper medical records. There were stacks of records from the doctors in Las Vegas and Reno, and the records from the recent visits to the clinic. Dr. Darko stayed late the evening before the day of her appointment, reviewing it all.

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Oh Joy. Oh, Really! The Big Day of Meeting the Psychiatrist

While she was pleasant enough and seemed to be trying to be open-minded, she felt seeing a psychiatrist was a put-down and an insult. And she said as much. When you’re a lady with worms crawling out of your skin, what help is a shrink? Dr. Darko was used to this attitude as a first hello. He repeated gathering her medical history, though of course with a psychiatric bent, and did the full-blown mental status exam part of the physical exam. Since the worms always came out of her forearms and hands, he spent a lot of time talking about them, why the skin might be rough for such a young woman, her jobs and career, and her life. Unfortunately, they ran out of time at that first visit and she had to schedule to come back. For some reason she didn’t seem that upset about this inconvenience.

Aha! Will Wonders Never Cease?

At that second visit she said that she had gotten interested in Dr. Darko’s questions about her arms and hands. She’d been thinking about that and his questions about her jobs and occupations. As it turned out, there was a time when the lady with worms crawling out of her skin worked for an antique auto restoration shop in Las Vegas. Not restoring cars herself but cleaning parts. The mechanics would tear a car apart for restoration, and separate out the parts that were too rusted or corroded to just brush off and put back. The shop employed several parts-cleaning people who would take the parts and clean them in these boxes. The shop also cleaned antique metal art objects and motorcycle restoration parts. Occasionally the odd piece of boat or bicycle hardware would show up.

An Old Shop with Old Equipment

She said the boxes were these boxes that were clear on the top and front, and the front lifted up to put things in the boxes. The front had two holes with thick black rubber gloves in them. A part-cleaner staff member would put the part in, close the front, put their hands and forearms in the gloves, and step on a peddle to shoot the cleaning sand on the part. The box protected the operator from the sand and the gloves protected the forearms and hands. She quit after a few months, though, because some of the boxes were old and the gloves had cracks and holes in them. If she couldn’t use one of the newer boxes and had to use an old one her arms and hands would hurt at night. She didn’t like the job, so the lady with worms coming out of her skin quit.

The Fine Art of Glass Bead Blasting

Shops and factories that clean and polish items use several types of “blasting” with different blasting media. Glass beads are one of the media used for blasting, including finishing, cleaning, deburring, and peening metal parts. Finishing is texturing a part after it’s been coated to give it a burnish. Cleaning is blasting off caked-on grime and dirt. Deburring is smoothing bits of metal left from welding, and peening makes cracks in a surface in a way that can help performance.

More Complicated Than She Wanted to Know About

The lady from Las Vegas didn’t know which of these blasting techniques she was actually doing, but she thought probably she had been cleaning, mainly because that’s what they called it. She didn’t put the sand in the blasting media holder, one of the mechanics put it in. She didn’t know if it was glass bead blasting media, they just called it sand. But she does recall them saying they don’t use real sand because it could be dangerous. Dr. Darko asked her to get details from the shop before their next visit.

The Worm Mystery is Solved

The people at the shop wouldn’t talk with her because they thought she was trouble and might sue them. In trying to find something out, though, she saw a new young guy working in the shop. She offered to buy him a drink if he’d talk to her about how the blasting really worked. He told her over a beer that they do glass bead blasting with a fairly large size glass bead media. He added that the shop owners are wary because some of their older blasting cabinets were leaky and had old, cracked gloves. People were getting hurt from the old boxes so they had to get rid of all of them. They bought all new cabinets. They didn’t want old employees coming around asking question and maybe causing trouble, like, for example, our lady with worms coming out of her skin.

The Worms Go In, The Worms Go Out

The truth began to dawn on the lady with worms coming out of her skin. And happily, before her next visit with Dr. Darko, another worm came out. Realizing now that it might not be a worm after all but just a glass bead, she looked at it carefully rather than fearfully brushing it quickly away. She picked it up and put it in a bottle to show Dr. Darko. It was a clear little glass bead but not smooth and round. It was irregularly shaped, like a funny little twist. No wonder she thought it was a worm!

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Everyone Hates Those Damn Psychiatrists

She was worried about one thing, though. She thought it odd that she was happy to go back and see the psychiatrist again. That worried her. Best not make a habit of THAT! That visit was indeed her last visit with Dr. Darko or with anyone at the big clinic on the coast. He doesn’t know if she decided to sue the restoration shop, but he guesses probably not. None of the clinic docs were ever called to give information or for a deposition. Likely, having evaluated her personality, she was happy to just forget about the whole thing and got on with her life, embarrassed that she ever thought she had worms coming out of her skin.

Helpful links:

National Institutes of Health on Parasitic worms and inflammatory diseases

Center for Disease Control and Prevention on Parasites

National Library of Medicine on Delusional Parasitosis: Diagnosis and Treatment

Pubmed Central – Public Attitudes Towards Psychiatry and Psychiatric Treatment

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